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Table 1 Citrate accumulation and alternative diagnoses: summary table

From: Complications of regional citrate anticoagulation: accumulation or overload?

  Citrate accumulation Citrate net overload Insufficient trisodium citrate delivery
Mechanism Incomplete citrate metabolism: persistence of circulating citrate–calcium complexes in the blood Excess citrate administration relative to buffer requirements Insufficient alkalotic load administered to the patient to adequately buffer acute kidney injury-associated acidosis
Diagnosis
 Acid-base Metabolic acidosis Metabolic alkalosis Metabolic acidosis
 Catot/Cai ratio Increased (>2.5) Normal (< 2.5) Normal (< 2.5)
 Other Increased need for calcium substitution Trend for a decreased ionized calcium level None None
Appreciation Potentially lethal (via severe hypocalcemia) Benign and easy to fix Benign and easy to fix
Incidence Rare Common Rare
Management Decrease blood flow or increase dialysate flow rate (if mild) Consider alternative anticoagulation strategy Decrease blood flow or increase dialysate flow rate Increase blood flow or decrease dialysate flow rate